The Big Debate

The Big Debate

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The Big Debate #13: Does independent prescribing move pharmacy away from its core role?

Started 29 days ago

This afternoon’s discussion will focus on the question: does independent prescribing move pharmacy away from its core role?

We’ve seen lots of changes in recent years as the sector makes the shift in pharmacy practice away from dispensing and towards clinical services.

But is the core role of community pharmacy really changing? And are the changes brought about by independent prescribing positive or negative? 

So, where along the spectrum do your own views lie? Join the Big Debate to tell us what you think.

We’re expecting lots of you will want to share your views on this important topic. Simply type your comment or question into the ‘leave a reply’ box below and let us know what you think.

The “live” part of the debate will close at 2pm, but feel free to continue to exchange views for as long as you like.

Join your pharmacy peers this afternoon to discuss:

  • What the core role of community pharmacy is and whether this is changing
  • Whether changes to the shape of the job brought about by independent prescribing are positive or negative
  • Should all pharmacists be IPs?

C+D has introduced a streamlined functionality that allows users to mention each other in a comment. Simply use ‘@’ and type in the person’s name.

This debate will start at 1pm.

Hello and welcome to this afternoon's Big Debate on whether independent prescribing moves pharmacy away from its core role. I'm C+D's news editor Cos Potter. I know we've got representatives with lots of experience from across the pharmacy sector including IPs and education providers ready to tell us what they think, so I'm looking forward to hearing everybody's views on this important topic. 

What the core role of community pharmacy is and whether this is changing?

We must define ourselves as independent health care professionals, who are not deputising for others, although it is a good service provision to do so. This is because we have a distinct skill set and knowledge base that others do not or are not in a position to exercise. Our core role remains to be the procurement of quality medicines and the supervision of their accurate dispensing. However, equally important is the fact that we provide medicines optimisation advice to patients and other professionals, in an evidence-based, patient-centred, and multidisciplinary manner. In the process, we have developed skills in the area of so-called minor illnesses (although they do not feel like ‘minor’ when you are really suffering) in the community pharmacy and other primary care centres. Minor illnesses is just one of the areas where change is happening (Pharmacy First), but change must be embraced in a continually developmental way as the NHS changes and as patient needs change. Independent pharmacist prescribing is a big boost to the management of minor ailments (see below) in primary care, and for the continued management of chronic illnesses in secondary care.

Are changes to the shape of the job brought about by independent prescribing positive or negative?

This is undoubtedly one of the most positive change that has taken place in our profession and industry. Being able to prescribe and having access to patient records is a direct method by which we have been able to connect with GPs and realised the NHS dream of seamless care in primary care. Doing this well will bring us the respect from GPs that we have long deserved. Pharmacies sit deep in the communities, within a twenty minute or less, walk-in distance of every individual. In this way a pharmacist can address minor illnesses immediately for almost every individual, and be able to refer and triage confidently, knowing that they have a full patient history and knowing that appropriate POMs can be prescribed on-site. The prescriptions can be done through PGDs (Pharmacy First) or as independent scripts (IP).

Should all pharmacists be IPs?

It is a good idea to be an IP, whether you work in hospital, community, or GP setting. But it is about what you want to do, or what you do best. That is where you will shine best.


1    Is the core role providing the medicines or giving advice on those medicines? 

THE CORE ROLE was pharmacists’ greatest area of expertise: the making, assembling, dispensing and/or final supply of corporeal, empirical medicines. They are THINGS.

IT IS CHANGING to advising and prescribing medicines (THE THINGS).
This question has been a hot potato for hundreds of years and led to jostling between pharmacy and medicine. The opportunity now exists to reestablish pharmacists in the community as tomorrow's GPs as they were in the middle of the 19th century. However, community pharmacists may have to delegate the procurement of the medicines (THE THINGS) to pharmacy technicians.

Note that chemists and biologists are already “taking over” making the THINGS. I fear that pharmacist may “forget” how to make medicines.

Hello, my name is Graham Stretch I’m a partner in a GP practice, and the president of the PCPA. I worked in Community Pharmacy for 20 years including as a prescriber. Today I’m speaking entirely in a personal capacity and not representing the views of any organisation that I’m associated with. 

Prescribing is simply a tool. By using this tool Community Pharmacy will be better able to meet the needs of our patients and the community.

As prescribing becomes a core and baseline competency for Pharmacists, practitioners will be able to better able to be the autonomous clinicians that our healthcare system needs. Prescribing actually streamlines many of the time consuming tasks Pharmacists in community and in GP have to undertake each day. I key block (and enabler) is read / write access to medical records.

I'll kick things off 

I think it's a great thing for our profession with the right supervision model.

I'm a primary care pharmacist that qualified in community and moved across to GP but am still very much engaged and in contact with community pharmacist colleagues, providing DPP support for them.

I am also one of the lecturer team at University of Brighton and teach on the MPharm degree where prescribing is now part of the initial education and the students are loving the increased clinical autonomy

Thanks for joining everyone! Wow a lot to think about! @Tarvinder Juss, how do you think being an IP allows you to shine?

@Danny Bartlett But how best to overcome the (justified?) caution may colleagues in community feel - risk, workload, training and access to records are common concerns

Hi @Malcolm Ernest Brown ! You're point that "pharmacist may “forget” how to make medicines" is one that is shared with others in the sector I think. What can do done to stop this happening in your opinion?

Thank you so much Tarvinder, Malcolm and Graham. Really interesting points to kick us off. Thinking about the core role of community pharmacy to start with - the 'hot potato' as you put it Malcom - how much do we really think this has shifted?

Hey All, My name's Shy and I'm one of the Chief Pharmaceutical Officer's clinical fellows this year. Interesting thoughts so far. 

@graham stretch 

As a community pharmacist, we routinely use our skills of history taking, assessment, clinical reasoning and shared decision making to deliver safe clinical care to patients. By becoming prescribers, we are allowing ourselves to better utilise these skills and become more effective. This greater level of accountability can lead to a better partnership with patients and potentially, an increase in job satisfaction.

This also presents us with a unique opportunity to develop our Pharmacy Technicians, our dispensers, and our counter staff to maximise the skill mix in our community pharmacies. The more we develop this skill mix, the less strenuous any potential changes to the job will be.

I think it's key to ensure that it part of initial education for the newly qualified pharmacists, though this may take some years.

With the legacy workforce the key is collaboration, read/write access is a MUST

It is like functioning blindly if you cannot see a patient's whole health record and we are spoiled as being the only ones with access in the primary care arena. Community pharmacy is part of primary care and not separate!

Collaboration is tricky but scratching the surface, reaching out to colleagues in secondary care and general pratice to gain insight to prescribing practices that are up and running will make it less daunting

@Danny Bartlett coming from an education perspective, have you noticed that this shifting in the pharmacist role has attracted more students to pharmacy?

Don't forget to hit refresh to see the latest replies!

The increased automation and delegation of dispensing to pharmacy technicians for accuracy checking, together with ever reducing financial returns for the supply functions in Community Pharmacy (no matter how much we may wish for a fairer payment system for this work) will lead to greater use of remote 'factory' dispensing and delivery of repeat medications. 

The USP of Community - access to all, without appointment must be safeguarded. Community Pharmacists need to be supported to gain the tools to manage a greater range of conditions both acute and long term - there lies the greatest opportunity. Pharmacy First is a step in the right direction. 

To overcome caution, dd more roles to pharmacy technicians. They are now deemed pharmacy professionals, (not pharmacists) and so presumably will carry their own  professional liability insurance. Note there is an important consultation on supervision ending at the end of THIS month. At all costs, a double-checking system, in my opinion, must be kept. Whether an AI is acceptable as one checker is an emerging suggestion. Note also the immensely detailed, and evidence-based cGXP (including GMP) guides for the pharmaceutical industry.

@Shy Teli Interesting to hear that developing skills mix might make the pharmacy "the less strenuous". What would you say to those who think that the work force is already too overwhelmed to take on new responsibilities?

 

@Kate Bowie Absoultely, the students are more engaged, their clinical skills and decision making has improved exponentionallly.

We aren't upskilling all of them to only go to GP and secondary care, the ones that choose community pharmacy will be able to be much more clinically autonomous and be able to help more patients than having to refer back to the GP for everything.

It means they will see the importance of follow up, safety netting and initiation of medications much more than before.

I absolutely understand the points around the busy environment and dispensary management, but that's where pharmacy technicians are more than ready to step up and take more of a leadership role in managing the workflow of the dispensary whilst the pharmacist runs chronic and acute disease clinics.

It's an exciting time to be in the profession we need to leap and not be scared to push our potential. With the right supervision and safety netting pharmacists can develop into competent and safe prescribers.

As a note these views are all my own and not in assosciation with any of my formal roles in the RPS, or University

@kate bowtie, I would encourage all community pharmacies to review their skill mix especially as the demands of healthcare and patients continue to develop. This is a good programme to help pharmacies do this: https://www.cppe.ac.uk/programmes/l/skillmix-e-02

I also think it's fascinating that many of us seem to have a different definition of what a community pharmacy's core role is. My definition was this: The core role of community pharmacy is to deliver safe clinical care to patients, as well as increase the value and sustainability from the medicines we use. I think that is still very much the case. 

@Danny Bartlett Yes Danny, that is how we will continue to shine in the community.

@Malcolm Ernest Brown I think once 'clinically checked' the accuracy part of supply can be safely undertaken via a combination of ACT (who must be regulated in my view) and automation/AI. 

The prescribing / dispensing separation is thornier with RPS releasing guidance this week.

The pharmacist as prescriber debate today, focuses on whether we feel in our current healthcare environment, this is a core skill. Patients should be able to expect this skill when accessing pharmacy services and our profession needs to assure both the training, credentialling and ongoing mentoring/supervision of these activities. It is a challenge.

Great points there about the role of pharmacy technicians in all this too. Perhaps we can talk a bit more about the positive and negative changes to the job that independent prescribing is bringing. What do we all think?

@Shy Teli I would go one step futher and simplify it further, all pharmacists in all sectors primary focus is medicines optimisation. Ensuring patients get the right medicine at the right time and the right dose. Everything else around that is logistical and can be managed by more than capable dispensary teams and pharmacy technicians

I used to manage an incredibly busy pharmacy, 30,000 items a month. I understand the restrictions on funding, staffing and the huge asks of the sector, and that is why we shouldn't shoulder all of the dispensary responsibilities and delegate this to registered competent pharmacy technicians

@Shy Teli Such a good point about everyone having different definition of community pharmacy 

These changes will all be a positive if they are being implemented in practice but unfortunately the situation is still that, there is a workforce shortage. pharmacists still need to be in the dispensary and most community pharmacies are not ready.

@Costanza Potter absolutely

Positives:

More clinically autonomous

Able to help patients more at the coal face rather than sending them to multiple professionals

Bringing the different sectors closer together

Increasing access and availability of medicines experts and their full potential

Being able to function so much more autonomously and making medicines optimisation part of everyday practice everywhere rather than a word batted around without being actioned fully by all in the profession

Negatives

Takes a time and hence financial toll so needs to be funded appropriately

Lots of community pharmacists to be 'prescribing ready' need clinical upskilling

When I moved into general practices examples of clinical learning needs I had that represents many colleagues in community pharmacy were: reading and interpreting blood tests, initiation and monitoring of medications when you are the prescriber, condition knowldege and red flag interpretation, physical assessment skills. 

@Tarvinder Juss You mentioned that one positive is that prescribing  "Doing this well will bring us the respect from GPs that we have long deserved". I think a few people on the chat have mentioned that pharmacists and GPs working together as one primary care is not only a positive but a necessary move for the NHS

A point well made about community pharmacists possibly being overwhelmed with demand. I have heard GPs expressing concern for pharmacists about them possibly being grossly, even dangerously, overworked in the new situation. One possible action is to consider some sort of triage system, not as extreme as the "dragon ladies (or gentlemen)" who protect GPs but some form of "filter". Even then, community pharmacists would remain FAR more "accessible" than GPs were.

I expect community pharmacists to become "the new GPs" from about 2026. as in the mid-19th century.

@Nana Ofori-Atta As always with any 'new' innovation (important to remember pharmacists have been prescribing for >20 years) there will always be the innovators and early adopters (see pathfinders) and those in late majority and laggards (see 'Diffusion of innovations' theory (Diffusion of innovations - Wikipedia)

The key is to facilitate those innovators and early adopters to get on with it and lead the way, whilst leaving the door open for the laggards. What is absolutely clear, is we can't wait for them. This I learnt the hard way from the pharmacists in GP pilots and PCN roll out. Those innovators need then to give a hand up and help those in the late majority through mentoring, supervision and communities of practice.

@Malcolm Ernest Brown I'm not sure i'm a fan of the 'new GP' title. We're clinicians in our own right with our own knowledge base. I teach a lot of GP trainee's and medics and can tell you we have an amazing plethura of knowledge they benefit from and vice versa, we are inherently linked but pharmacists deserve their own right and names rather than coming under the wing of a different profession, we can stand alone in collaboration.

@Nana Ofori-Atta My view was that biggest changes that independent prescribing will bring is an increased job satisfaction. And that will lead to more people wanting to work in community pharmacy! Do you think it will? 

It always comes back to funding doesn't it! I like your point Graham about those who are early adopters having a role in giving a "hand up" to the rest, though. 

@Malcolm Ernest Brown Care needed with this, I know what you are trying to say but I have no interest in being a 'non-medical' anything or 'a new GP' - rather I want us to be Pharmacists - Super ones even. 

Prescribing medications (and deprescribing just as importantly), monitoring, reviewing and optimising medicines is our core function, we need to accept this and take ownership regardless of sector or setting

@Malcolm Ernest Brown Very good point about pharmacists returning to their roots, so to speak, and also about the risks of pharmacists becoming even more "dangerously" over worked. 

@Danny Bartlett  do you think IP is currently being "funded appropriately"?

Great question Shy - I'd love to know the answer too... Could this be part of the answer to making community pharmacy a more attractive place to work?

@Graham Stretch Yes there are pharmacies that have manage to adopt to the changes better than other but this is suppose to be a public service ad the fact remains that the community sector has been hit with a lot of major changes but the funding is yet to reflect to investments required to make these changes.

Devil's advocate point: What about dispensing though? Should the government and educational bodies be putting so much time and money into prescribing when we still haven’t got a sustainable dispensing model? 

  • What the core role of community pharmacy is and whether this is changing

The core role should progress to clinical activity, including reviewing patient pharmacotherapy and the clinical appropriateness of new and existing medicines. Dispensing - and accuracy checking - are technical tasks which does not require five years of university training. I spent far to many years sat in the corner of a dispensary checking prescriptions which wasn't a good use of my skills for patients or the NHS. 

I see some concerns about pharmacists no longer knowing 'how to make' medicines, but to me that's not a concern. We should align pharmacist training (whether undergraduate or postgraduate) to what the majority of pharmacists actually do i.e. provide patient care. I spent years studying chemistry and pharmaceutics during my undergraduate degree, and aside from some pharmaceutics, haven't used it since. There is a disconnect between degree and role, which I feel is finally being rectified with the new standards for initial education and training. Clinical pharmaceutics is our niche and specialism, so we should protect that within curricula to some extent. 

  • Whether changes to the shape of the job brought about by independent prescribing are positive or negative

Positive. Pharmacists prescribed long before 'prescribing rights', for example via counter prescribing. The key advantage of pharmacist prescribers for patients is access to ensure equitability of care. The health system in its current form limits access to care. 

Also, prescribing is just one 'outcome' of a consultation; pharmacy as a profession tend to place great emphasis on 'prescribing', but it depends what we mean by that. Writing a prescription is a tiny part of the consultation process, which is informed by history taking, clinical examination, investigations, tests et cetera, all of which is underpinned by clinical reasoning. The latter is something poorly researched and understood. 

  • Should all pharmacists be IPs?

Yes, if they have undertaken a suitable MPharm programme or postgraduate training.

@Shy Teli Absolutely, the single greatest enabler I experienced in community practice was prescribing. Together with a laptop with full notes access and pads (well before EPS) of Rx for local surgeries. This developed into a pharmacy based service where repeat Rx management (largely by pharmacy technicians) was commissioned by GP surgeries, long before any central funding or PCNs

Many would seek community jobs with this scope of practice I am sure.

@Shy Teli I think instead of improving job satisfaction it will actually increase the already enormous amount of pressure involved in working as a community pharmacist. 

@Kate Bowie I think the funding for the courses should be less messy and more centralised, no one should have to self fund a prescribing course if it is now part of the initial training.

In regards to DPP's, I think all we need is the backfilled time and this again should be centrally funded.

I've heard stories about DPP's charging many thousands just to supervise a trainee prescriber, it should strictly cover the hourly rate of the prescribing professional in post. Worked out this is around £1500-£2000 per DPP for 45 hours supervision plus administrative time and linking trainee with other prescribers for the other 45 hours, nothing more than that. Any DPP charging more than this should not be making a profit from upskilling a colleague it should be a standardised fee nationwide

@Nana Ofori-Atta funding is the single greatest barrier. Without money for investment in teams we are held back. It is true across primary care

 

Welcome Daniel - great to hear from you. You talk about the disconnect between degree and role - is there anything there you think still needs work?

Good point about future names.

Any suggestions?

Medico?

Healer?

First contact practitioner (FCP) as already used by some apex physiotherapists?

Note the legal judgement around 1828 that there were FOUR degrees in the medical profession:

physician;

surgeon;

apothecary and

CHEMIST AND DRUGGIST;

the last group could not join the earliest medical register because they already had one as "pharmaceutical chemists" (now "pharmacists").

I believe that pharmacists also retain the legally restricted title of "pharmaceutist".

It is a common sociological strategy to change a group's name when claiming a new or "enhanced" role during a "turf war". But co-operation with medical practitioners is far better.

We're running out of time so I'd love to move onto our last question. I know some of our excellent speakers have already addressed this but I'd love to hear everyone's views - should all pharmacists be IPs?

Malcolm  - we certainly would love to see a return to the name Chemist and Druggist!

@Costanza Potter No advertising allowed :-)

@Costanza Potter I would say upskilling in every role is a positive thing but i don't think that all pharmacists should be IPs, there are other roles in the sector that does not require a practitioner to be a prescriber. 

Haha, chemist and druggist works so well! 

With regards to the las questions @costanza potter, I think YES! By all becoming IPs, we allow ourselves to create a fully flexible workforce that is responsive to the changing needs of our local patients and healthcare system. This also allows us to play a greater role in reducing healthcare inequalities as we will be able to provide consistent services across the country.

@NANA K OFORI-ATTA Fair point re pressures - Prescribing streamlines a number of the 'pressures' in Community - out of stocks, Rx orders not fulfilled/in error, emergency supplies for example all easier when you can prescribe alternatives, or expedite Rx - depends (for safety) on access to record)

All pharmacists should be IPs, as long as appropriately trained via a suitable MPharm or postgraduate training. Both of these require experience in practice - often far more than is currently included in these programmes. 

We also need to eventually move away from the terms 'independent prescriber' and 'non-medical prescriber' and simply use 'prescriber' - which in itself will eventually become redundant as all pharmacists will be a prescriber. 

@Daniel Greenwood  You mention that clinical reasoning is "poorly researched and understood" - do you mean within the sector? How can this be amended if going forward all pharmacists should be IPs?

Also, the GPhC register should have categories for 'practising' and 'non-practising', so that those who move into non-clinical roles are clearly identifiable. Those without ongoing experience shouldn't be prescribing. 

That leads onto re-validation, which needs an overhaul...

@Costanza Potter  All pharmacists should be IP.

At qualification, and if desired, as a 'legacy' pharmacist. 

If some choose not to that's absolutely fine, but their scope will be increasingly narrowed as these competencies become the norm.

Clinical reasoning by pharmacists has been seldom researched; most of the literature relates to medics and nurses. We need to understand how pharmacists make clinical decisions in the context of their previous training (greater scientific focus than other healthcare professionals, in general), and their role. 

Thank you so much for all these points: very stimulating. We are living in turbulent and exciting times.

We've got just five minutes left of the 'live' part of today's debate. However, you're welcome to continue posting your views and interacting with one another for as long as you like

Interesting point about categories on the GPhC register Daniel - I hadn't considered that before...

'You mention that clinical reasoning is "poorly researched and understood" - do you mean within the sector? How can this be amended if going forward all pharmacists should be IPs?'

So @kate bowie, this is how you define someone who is a professional in their own right (e.g. not a GP deputy), by having their own independent evidence-base. Pharmacists should research and publish this aspect in top clinical journals.

@daniel greenwood - interesting point about clinical reasoning research. 

@Tarvinder Juss and @Daniel Greenwood thanks both for the explanation - further academic discussion definitely sounds like an important aspect of changes to prescribing

Good afternoon all - with 18042 of our number prescribers out of 64104 (Dec) - that's >28% - we are at a tipping point where increasingly the ability to prescribe will be expected of us. On a local 50000 member facebook page there are often questions 'which pharmacy has a prescriber' - it confers a commercial advantage, improves access and patient care - win, win situation.

Phew - what a great debate. It's been so fascinating and invigorating to read all your perspectives and think about angles I've never considered before.

This concludes the live part of today's debate, but please feel free to continue posting your views for as long as you like. We'll see you again next time for C+D's Big Debate.

Thanks so much for joining us and sharing your views!

Thanks all!! Great to hear everyone's point of view and learn about the problems you all forsee - will definitely bear in mind all of these points going forward :)  

Hi,

my name is Gareth & I am community pharmacist.

My employer wants pharmacy first pushed ahead of dispensing medications.

My store however has lost 3 dispensers & has no qualified counter assistants.

With pharmacy cutbacks the bones of pharmacy, which is medications, is being overshadowed by corporate greed.

While I'd love to do my I.P. course, I can only see it making my workload even more unrealistic....

& don't even get me started on Pharmacy First which is a complete shambles & money grabbing opportunity for chains (& excuse to bully locums & employed pharmacists into self certifying when they don't feel safe doing the services).

We are PHARMACISTS! We shouldn't have to do thid ridiculous tangent to our already unmanageable workload.

i just emailed the PDA to see if community pharmacists could coordinate strike action.

@gareth ashley I feel both sad and angry to hear this, and I feel very sorry for you. What you are saying is straightforward; three dispensers have left, and you cannot guarantee safety at the counter because staff are not trained. As RP, your position is already in danger, but this does not concern the managers because they are not the RP (i.e. it is not their responsibility). So the managers put you under further pressure to deliver Pharmacy First for profit, putting you and your patients in further danger. The IP course, understandably, should be the last thing on your mind. I too know what I need to say about how we are running community pharmacies, and in whose hands we are putting our community pharmacies, in our country. However, like so many others who have to put food on the table, I am too scared.

@gareth ashley You mention the PDA. I would say that the torture you are going through is exactly the reason why trades unions were devised; to prevent the pursuit of profit putting undue pain on the employee. But alas, this is not a political website, and my politics are middle of the road.